Self-reported violations during medication administration in two paediatric hospitals

1Human Factors Practice, Exponent Failure Analysis Associates, Chicago, IL USA (work completed while a PhD student in the Department
of Industrial and Systems Engineering of the University of Wisconsin)

2Departments of Medicine and Biomedical Informatics, Vanderbilt University, Nashville, TN, USA (work completed while a Postdoctoral
Fellow at the School of Medicine and Public Health at the University of Wisconsin)

3Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI USA

4Department of Pediatrics, Vanderbilt University, Nashville, TN, USA

5Departments of Pediatrics, Public Health, and Medicine, Weill Cornell Medical College, New York, New York, USA

6Department of Pharmacy, St Mary's Hospital, Madison, Wisconsin, USA

7School of Nursing and Department of Family Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA

8Department of Industrial and Systems Engineering and Systems Engineering Initiative for Patient Safety, University of Wisconsin,
Madison, WI USA

Abstract

Content Violations of safety protocols are paths to adverse outcomes that have been poorly addressed by existing safety efforts.
This study reports on nurses' self-reported violations in the medication administration process.

Objective To assess the extent of violations in the medication administration process among nurses.

Design, setting and participants Participants were 199 nurses from two US urban, academic, tertiary care, free-standing paediatric hospitals who worked in
a paediatric intensive care unit (PICU), a haematology-oncology-transplant (HOT) unit or a medical-surgical (Med/Surg) unit.
In a cross-sectional survey, nurses were asked about violations in routine or emergency situations in three steps of the medication
administration process.

Main outcome measure Self-reported violations of three medication administration protocols were made using a seven-point 0–6 scale from ‘not at
all’ to ‘a great deal’.

Results Analysis of variance identified that violation reports were highest for emergency situations, rather than for routine operations,
highest by HOT unit nurses, followed by PICU nurses and then Med/Surg unit nurses, and highest during patient identification
checking, followed by matching a medication to a medication administration record, and then documenting an administration.
There was also a significant three-way interaction among violation situation, step in the process, and unit.

Conclusions Protocol violations occur throughout the medication administration process and their prevalence varies as a function of hospital
unit, step in the process, and violation situation. Further research is required to determine whether these violations improve
or worsen safety, and for those that worsen safety, how to redesign the system of administration to reduce the need to violate
protocol to accomplish job tasks.

Footnotes

Funding This study was funded in part by a grant from the Agency for Healthcare Research and Quality (R01 HS013610, Karsh PI). RJH
was supported by a pre-doctoral training grant from the National Institutes of Health (1 TL1 RR025013-01) and a post-doctoral
training grant from the Agency for Healthcare Research and Quality (5 T32 HS000083-11).